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“I think a therapist would have a field day with someone like Michael Ginsberg,” actor Ben Feldman told Vulture yesterday, following his nipple-mutilation episode of Mad Men. To which we said: challenge accepted! Psychiatrist Dr. Paul Puri has analyzed Mad Men characters for Vulture before (see here, here, and here), though prior to Sunday night, none of them had been literally wheeled out of the SC&P office in a gurney. Ginsberg’s total psychotic break can be read as a metaphor for the breakdown of American society in 1969, but how does it read from a medical perspective? We spoke with Dr. Puri about schizophrenia, castration metaphors, and Ginsberg’s likely prognosis (which is actually not so bad).

Let’s begin at the beginning: Ginsberg had a rough start in life. He was born in a concentration camp.Everybody says he was born in a concentration camp because of that speech in “Far and Away.” What’s interesting to me about that is he doesn’t actually say he was born in a concentration camp; he says he was told he was born in a concentration camp. So regardless of whether it’s true, he doesn’t necessarily identify with that.

What does he identify with, then?He feels cut off from things, but he identifies to a degree, it seems, as a Jew post-Holocaust, and he identifies as someone creative who’s never quite taken seriously. Which fits with his crying out “What am I, Cassandra?” because Cassandra was someone who had the power of prophecy but was never really taken seriously.

How do we get from there to nipple mutilation?I think you can approach this question two different ways. Through the contemporary psychiatric lens, which is very biology-based, the show has really dropped hints all along that Ginsberg is an odd guy and possibly on the schizophrenia spectrum. He says things that can be a little weird. He has difficulty filtering himself, which is characteristic of schizophrenia; there was a presentation that he had to give once where he just couldn’t hold back from giving the negative side of things. Some schizophrenics misinterpret things as being reality that aren’t reality, and then they end up with thoughts coming in that are paranoia or auditory hallucinations, as if thoughts are disconnected and coming in as voices. There’s mis-wiring of the brain, so that things are coming in as sensory signals that are not necessarily, and so they get sort of distorted perception of reality.

Why did the computer trigger Ginsberg’s break from reality?He had this outlet that gave him permission to be creative and kept him functional. And then the computer came in, and it took away his creative space. It took away his place to do that. For somebody who might already be a little bit fragile, that might be something that pushes them over the edge.

But then he also talks about the computer’s background humming. Now, with people that have a meth addiction, which can very much look like schizophrenia at times, what’s interesting is that a white noise generator, or even a washing machine, can actually bring on hallucinations in some people. They hear things within that. And so I thought it was very interesting that it’s really the hum that pushes things over the edge in this most recent episode. He even tries to use tissues for ear plugs, and he talks about how the computer is whispering. I’m making a leap here, because we don’t quite have the evidence to support this, but it’s almost as if he’s hearing messages in the humming sound.

Schizophrenia is a likely diagnosis, then.This seems like a first-break psychosis episode for somebody who might have schizophrenia, it’s a little early to tell, because people can have a single psychotic episode and then it goes away mysteriously. But schizophrenia is probably a hundred different diseases. It’s all these different little genetic and other abnormalities in different places in the brain that produce similar symptoms, but not exactly the same. They can be auditory hallucinations, or bizarre thoughts, or bizarre beliefs, they can be paranoia, magical thinking, all these different kinds of things. So in that context, it would seem like Ginsberg had a first psychotic episode, or a psychotic break. Back then, they probably would have said he had a nervous breakdown.

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You said there was another way to approach the question.Well, if we were looking at the psychoanalytic side, I would bring up the idea of the computer being “the monolith,” which was the title of last week’s episode, and the fact that Ginsberg was adopted by this guy Morris out of an orphanage, so he’s never had a mother figure. So we have this phallic image of the monolith — and I don’t necessarily buy into this, but this may be an approach they’re using in the creation of the show — and Ginsberg is worried that the computer is trying to "erase him." It's a metaphorical castration, if you will. But as someone who doesn't identify with all the men around him, he doesn't know how to respond as a man. In his world, maybe being a man, or being homosexual, is equated to him as being feminine. He tries unsuccessfully to "be a man" in the traditional way by "procreating" with Peggy. When that doesn't work, his psychotic thinking involves becoming a man by cutting out the feminine, his own breast. Or at least a nipple, in this case. He gives it to Peggy to show how he's taken back his manhood.

That got very Freudian very fast.I’m just making stuff up, but that’s how you do this! The common critique of Freud is that it’s not evidence-based, it’s one guy sitting around making up an entire theoretical system without any real other external evidence or validation behind it. But it’s one way to view the world, and I don’t necessarily buy it, but I suspect that the writers of Mad Men have some resonance with it, so it’s worth discussing.

You mentioned the possibility that Ginsberg has some repressed homosexual tendencies.Right. The typical model of repressed or latent homosexuality means that being homosexual is unacceptable, therefore it gets projected out and seen in others. In this case, he sees Lou and Jim Cutler having their secret conversation, and inferrs it must mean they're gay. And then attributes it all to the computer, making them "do unnatural things." This again reflects the stress of the phallic object reminding him of what's unacceptable to him, and putting it onto others. Really, a computer is just a computer. For Ginsberg, it's something that's trying to force him to be homosexual. And he'd rather cut off his own nipple than allow himself to be homosexual. One might even go so far as to say the only way to be a man, for him, is by removing what's feminine about him, which is his own breast. Now we're really reaching.

Well, cutting off a nipple isn’t a common symbolic gesture.Absolutely not. But self-mutilation, unfortunately, happens in people with psychotic thinking, and it’s not always clear how it ended up happening. I’ve seen people who gouged out their own eyes, or mutilated their bodies in various other ways. An analyst would try and play with the idea of why he chose the nipple. All we know from Ginsberg is “it’s the valve,” so it “flows” now.

What kind of treatment is Ginsberg likely to receive in 1969 after they wheel him out of the office?He would probably be put on some kind sedative, and he may also be given an antipsychotic, like Haldol. Psychoanalysis was still very big at the time, so he might end up in a mental hospital and get treated. That’s assuming that this isn’t full schizophrenia, and we don’t really have evidence that it is. Usually schizophrenia has a lead-in period, what we call a prodromal period — a drop-off where people get isolated and they withdraw and have trouble focusing and might even seem depressed — and then you have the bigger sort of break. Because he doesn’t have a whole lot of a prodrome, he’ll probably be much more responsive to treatment. So he may be back on the show. Who knows?

In terms of modern treatment, what kind of course would you recommend?Based on this episode, I would try and get a better diagnostic interview, to ascertain how long this has been going on and if this is really a psychotic break. It’s likely that I or someone would give him a new antipsychotic medication. He’s what we call neuroleptic naive, meaning he’s never been on something. So we’d put him very low on a dose, and probably observe him in the hospital for a couple days to see how he responds to that. And then he would probably be discharged from the hospital and scheduled to see somebody at an outpatient basis. We would also want to make sure that there’s not any affective disorder like depression or bipolar disorder underlying this, because that would take a different treatment approach; you’d want to make sure the mood disorder is being treated too. In therapy, I would probably explore whether him getting back into some kind of a functional life — like, giving him some other creative work in a more structured environment that he can handle — would improve his functioning in the long term.

So is Peggy going to be permanently traumatized by the sight of gift boxes?Yeah, probably. [Laughs.]